irritable bowel syndrome
DESCRIPTION
Irritable Bowel Syndrome. Dr Bruce Davies. Introduction. First described in 1771. 50% of patients presentTRANSCRIPT
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Irritable Bowel Syndrome
Dr Bruce Davies
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Introduction First described in 1771. 50% of patients present <35 years old. 70% of sufferers are symptom free after 5
years. GPs will diagnose one new case per week. GPs will see 4-5 patients a week with IBS. Point prevalence of 40-50 patients per 2000
patients.
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What Is IBS? A syndrome. One man’s
constipation is another man’s normality.
Cause unknown. 20% seem to start
after an episode of gastroenteritis.
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Diagnostic Criteria Rome 11 Diagnostic criteria.
Manning’s Criteria.
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Rome 11 Diagnostic Criteria. At least 12 weeks history, which need not
be consecutive in the last 12 months of abdominal discomfort or pain that has 2 or more of the following:– Relieved by defecation.– Onset associated with change in stool
frequency.– Onset associated with change in form of the
stool.
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Rome 11 Diagnostic Criteria. Supportive symptoms.
– Constipation predominant: one or more of: BO less than 3 times a week. Hard or lumpy stools. Straining during a bowel movement.
– Diarrhoea predominant: one or more of: More than 3 bowel movements per day. Loose [mushy] or watery stools. Urgency.
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Rome 11 Diagnostic Criteria.
– General: Feeling of incomplete evacuation. Passing mucus per rectum. Abdominal fullness, bloating or swelling.
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Manning’s Criteria. Three or more features should have been
present for at least 6 months:– Pain relieved by defecation.– Pain onset associated with more frequent stools.– Looser stools with pain onset.– Abdominal distension.– Mucus in the stool.– A feeling of incomplete evacuation after
defecation.
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Associated Symptoms In people with IBS in hospital OPD.
– 25% have depression.– 25% have anxiety.
Patients with IBS symptoms who do not consult doctors [population surveys] have identical psychological health to general population.
In one study 70% of women IBS sufferers have dyspareunia.
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Associated Symptoms Stressful life events are associated. Compared with controls people with
IBS are less well educated and have poorer general health.
Women:Men = 3:1.
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Reasons to Refer Age > 45 years at
onset. Family history of bowel
cancer. Failure of primary care
management. Uncertainty of
diagnosis. Abnormality on
examination or investigation.
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Urgent Referral Constant abdominal
pain. Constant diarrhoea. Constant
distension. Rectal bleeding. Weight loss or
malaise.
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Subtypes Diarrhoea predominant. Constipation predominant. Pain predominant.
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Differential Diagnosis Inflammatory bowel disease. Cancer. Diverticulosis. Endometriosis.
A positive diagnosis, based on Manning’s criteria may provoke less anxiety than extensive tests.
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Examination Results should be
normal or non-specific. Abdomen and rectal
examination. FBC, CRP. No consensus as to
whether FOBs or sigmoidoscopy is needed.
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Treatment Patients’ concerns. Explanation. Treatment
approaches.
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Patients’ Concerns. Usually very concerned about a
serious cause for their symptoms. Take time to explore the patients
agenda. Remember that investigations may
heighten anxiety.
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Explanation. Must offer a plausible reason for symptoms. Even if cause is unknown, patients require
some explanation. Drawing a parallel with baby colic may help. Stress is currently a socially acceptable
explanation for many symptoms in life.
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Treatment Approaches. Placebo effect of up to 70% in all IBS
treatments. Treatment should depend on symptom
sub-type. Often considerable overlap between
sub-groups.
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Antidepressants Poor evidence for efficacy. Better evidence for tricyclics. Very little evidence for SSRIs.
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Diarrhoea Predominant. Increasing dietary fibre is sensible
advice. Fibre varies, 55% of patients will get
worse with bran. “Medical fibre” adds to placebo effect. Loperamide may help.
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Constipation Predominant. Increased fibre. Osmotic laxatives helpful. Ispaghula
husk is one. Stimulant laxatives make symptoms
worse. Lactulose may aggravate distension
and flatulence.
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Pain Predominant. Antispasmodics will help 66%. Mebeverine is probably first choice. Hyoscine 10mg qid can be added. Bloating may be helped by peppermint
oil. Nausea may require metoclopramide.
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Diet Dietary manipulation may help. Food intolerance is common food
allergy is rare. Relaxation therapies may be useful
adjunct.
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Referral About 15% of patients seen by GPs
with IBS are referred. Gastroenterology – Mainly upper GI
symptoms. General Surgical – Lower GI
symptoms.
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Self-help IBS network, St
John’s House, Hither Green Hospital, Hither Green Lane, London SE13 6RU
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Audit? Numbers on repeat prescription for anti-
spasmodics. Do they use their drugs as prescribed? What other medications do they use? Referral rates? What investigations are done? Protocol? Formulary?
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Psychological Thoughts Should a mental health assessment
always be done? Should all therapy be directed at
psychological causes? Is IBS a physical or a somatisation
disorder?